Pharmacist‑led e‑consults aim to reduce pneumonia risk in people with HIV

Dr. Kristina Crothers, professor (Pulmonary, Critical Care and Sleep Medicine) and VA Puget Sound Health Care System Chief of Pulmonary, Critical Care and Sleep Medicine, has been awarded a 5-year $4.2 million R01 grant by the National Heart Lung and Blood Institute to support an initiative designed to improve lung health and reduce pneumonia-related illness among people with HIV. Dr. Ken Kunisaki, director of Clinical and Translational Research at the Boise VA, is also a principal investigator.

Despite effective antiretroviral therapy (ART) for people with HIV (PWH), community-acquired pneumonia remains a common cause of complications, hospitalization and death. Pneumonia continues to be substantially more common among PWH compared to people without HIV, and risk increases with age and comorbidity.

Several modifiable factors also contribute to increased risk, including active smoking, inadequate vaccinations, and commonly used potentially inappropriate medications such as inhaled corticosteroids (ICS) and proton-pump inhibitors (PPIs).

Aiming to improve guideline concordant care and reduce the population level risk of pneumonia among PWH by addressing these factors, Crothers and colleagues have developed a pharmacist-led proactive E-consult intervention to facilitate recommendations for patients at the Veterans Health Administration (VHA). The program, called OPTIMIZE Lung-HIV, will leverage strategies from an existing pulmonologist-driven E-consult intervention and adapt it by partnering with pharmacists for implementation.

The team will conduct a multicenter, patient-level randomized controlled trial to assess whether these proactive E‑consults more effectively prompt evidence-based medication changes compared to usual care, and evaluate factors influencing implementation of the program.

At each participating site, Veterans with HIV will be identified who have potentially modifiable risk factors for pneumonia; pharmacists will review the patient records and intervene with recommendations to promote smoking cessation pharmacotherapy, ensure guideline-concordant vaccinations, and deprescribe inappropriate ICS and PPIs.

The E-consults will be delivered via the electronic medical record and orders pre-entered for the patient’s provider to enact, modify or cancel if they disagree, facilitating implementation while maintaining provider autonomy.

As pharmacists are already integrated into primary and specialty care in the VHA, this model offers opportunities to extend the national reach of the intervention and may be a realistic and cost-effective option for improving lung health and decreasing risk for pneumonia in people with HIV. If effective, the proactive E-consult model can be readily adapted for other pharmacist-led medication management recommendations.  

“We are really excited for the OPTIMIZE Lung-HIV trial,” Crothers said. “In prior grant-funded work with my VA colleague Dr. David Au, professor (Pulmonary, Critical Care and Sleep Medicine), at the VA Puget Sound Health Service Research Center, we have found that pulmonologist-driven proactive E-consults are effective in improving quality of care for chronic obstructive pulmonary disease for both people with and without HIV, and to be very acceptable to providers.

This new grant will allow us to expand the scope of our intervention with assessing new medications, determine costs of the program, and develop a more scalable model for E-consults by leveraging the skill set of pharmacists.”